The business record for a patient encounter that documents health care services provided to a patient is called a

medical record

Patient identification information collected according to facility policy, which includes the patient's name, date of birth, and so on, is called

demographic data

A paper based record is called a _______ record

manual

The patient's diagnosis must justify diagnostic and/or therapeutic procedures or services provided, which is called

medical necessity

The primary purpose for the record is to provide for __________, which involves documenting patient care services so that others who treat the patient have a source of information on which to base additional care.

continuity of care

When reports are organized according to data source, the _________ record is being used.

source oriented

When reports are arranged in strict chronological order, or reverse date order, the ___________ record is being used

integrated

An automated record that is created on a computer using a keyboard, a mouse, an optical pen device, a voice recognition, a scanner, or a touch screen is called the

electronic medical record EMR

An automated record that provides an alternative to traditional microfilm or remote storage systems because patient records are converted to an electronic image and saved on storage media is called

optical disk imaging or doc imaging

The equipment that stores large numbers of optical disks resulting in huge storage capabilities is called

Hospital coders use automated ______ software to collect and report inpatient and outpatient data for statistical analysis and reimbursement purposes

case abstracting

Physician's offices submit data to third party payers on the _______ claim

CMS-1500

Hospitals submit data to third party payers on the _______ claims

UB-04

Claims are denied if _______ of procedures or services is not established

medical necessity

ICD-9-CM was adopted in ___ as the official classification system for assigning codes to diagnoses and procedures

1979

The ICD-9-CM was originally published as ___ volumes

three

The US Dept of Health and Human Svcs agencies responsible for overseeing all changes and modifications to ICD-9-CM are_____

National Center for Health Statistics NCHS and Centers for Medicaid and Medicare Svcs CMS

The _____ requires all code sets to be valid at the time services are provided, which means that midyear and end of year coding updates must be implemented immediately so accurate codes are reported on claims

Medicare Prescription Drug Improvement, and Modernization Act MMA

Updateable coding manuals which publishers offer as an annual ______service, are popular because coders can remove outdated pages and insert updated pages into the binders

subscription

The coding process is automated when computerized or web based ______ software is used instead of coding books to lcoate codes manually - the coder uses the software's search feature to locate and verify codes

encoder

The mandated reporting of ICD-9-CM diagnosis codes on Medicare claims was implemented by the _______

Medicare Catastrophic Coverage Act of 1988

Reporting ICD-9-CM codes on submitted claims ensures the ______ of procedures and services provided to patients during an encounter which is defined as the determination that a service or procedure rendered is reasonable and necessary for the diagnosis or treatment of an illness or injury